GOVERNMENT OF MAHARASHTRA

(RECRUITMENT OF BAMS MEDICAL OFFICER)

Post Applied For:

Name
Recent Passport size
photograph
Name
Marathi

Father's /Guardians'
Name

Mother's Name

Father's /Guardians'
Occupation
Candidate Signature (in Box)
Gender Marital
Status
Date of Birth Age as on
(31.03.2017)
Mother Tongue 1. E Mail-ID
2. Phon No-

Contact and Marital Information :

Correspondence Address .

Correspondence Address in
Marathi

Permanent Address

Permanent Address in
Marathi
Whether Spouse working Spouse
with Govt.Department? Place of
Posting
Profession of the Spouse

Reservation :
Category ' Cast
Certificate
Cast Sub Caste

Non-Creamy Layer Certificate Annual

Income
Social Reservation

Physically Handicapped
Fees Details :

SR.No Demand Draft No. Amount Bank Name

1

General Information

Possesses Adequate Knowledge to read,

write and speak Marathi Language
Date of Completion of Compulsory
Rotating Internship (dd/mm/yyyy)
Date Of Registration Registration Number Date of Renewal
(dd/mm/yyyy) (If
any)(dd/mm/yyyy)
Has successfully completed MS-CIT ?

Preferred Area of Posting ?

MBBS Yearwise Marks:

Year Marks Out of Marks

1St year

t year

3st year

4st year

Total

Percentage Mark in
MBBS
Has any other Post
Graduate
Degree/Diploma in
other medical subject
Subject

Qualifying Examination

Sr.No Facult Progra Specialisatio Board Passin Class Total Marks Total Percentag
y m n Universit g Year Obtained Out of e
Y Marks
1

Experience :
Sr.No Post held Organization Name Organization Nature of Is the
Address Appointmen Office/Institution
t owned by Govt. of
Maharashtra
Sr. No Exact dates to be Total Period Scale of Basic Pay Nature of Reasons for leaving along
given (From-To) (Year/Month Pay (In Rs.) Post with discharge certificate
/Days)

Total Experience : (A) Before essential Qualification

 (B) After essential Qualification

(C) After higher Qualification

Required Documents :

Sr.No Documents
1.

2.

3.

4.

5.

I hereby declare that all the information furnished by me in this application from are true, complete and
correct to the best of my knowledge and belief. I do understand that I need to obtain and produce all the
required original certificates enlisted in the form by me at the time of document verification. I understand
that entries made by me in this application form are final and binding on me. I further declare that in the
event any information being found false or incorrect I shall be liable for disqualification as mentioned in
the notification.

Place

Date Signature of the Candidate

 Affidavit
Affidavit to be furnished by a person along with the Application for the post of
Medical Officer MMHS Group A in the pursuance of the Advertisement Number
01/2015 Dated published by Selection Board For Medical Officer
Recruitment, Established by Public Health Dept.
Govt. of Maharashtra.

I son/daughter/wife of... aged about

years, resident of Do hereby solemnly affirm/ state on oath as
under :-

1. I have submitted my application for the Post of

In pursuance of the Advertisement No 01/2015 dated

2. I have read the provisions in the Rules and Notification of the Selection Board
carefully and I hereby undertake to abide by them. I further declare that I fulfill all the
conditions of eligibility regarding age limits, educational qualifications, experience if
any, concession etc. prescribed for the Post herein above.

3.1 hereby declare that all the statements made in this application are true, complete
and correct to the best of my knowledge & belief. In the event of my information
being found false or incorrect or I am detected ineligible, I am liable to be dismissed
from service.

4. If information given in this Affidavit on oath is found to be false i.e.not supported

by documentary proof at the time of verification by Selection Board, I will be liable to
Blacklisted and Debarred from all further examinations and selection processes of
the Selection Board; and liable for disciplinary proceeding if already in Government
Service.

Place
Date : Signature of Deponent

VERIFICATION

I, the above named deponent do hereby verify and declare that the contents of this
Affidavit are true and correct to the best of my knowledge and belief. No part of it is
false and nothing material has been concealed therein.

Verified at ms day of 20....

Deponent